Management of Spontaneous Pneumothorax
The management of spontaneous pneumothorax should be based on pneumothorax type (primary vs. secondary), size, and patient symptoms, with simple aspiration recommended as first-line treatment for symptomatic primary pneumothoraces requiring intervention, while secondary pneumothoraces generally require more aggressive management with chest tube drainage. 1
Classification and Initial Assessment
- Primary Spontaneous Pneumothorax (PSP): Occurs in patients without underlying lung disease
- Secondary Spontaneous Pneumothorax (SSP): Occurs in patients with underlying lung disease (COPD, emphysema, etc.)
Size Assessment
- Small: Small rim of air around lung
- Moderate: Lung collapsed halfway toward heart border
- Complete: Airless lung, separate from diaphragm
- Tension: Any pneumothorax with cardiorespiratory collapse (requires immediate intervention) 1
Treatment Algorithm
1. Primary Spontaneous Pneumothorax
Small PSP with Minimal Symptoms:
- Observation alone is recommended
- No hospital admission required
- Patient education to return if breathlessness develops
- High flow oxygen (10 L/min) if hospitalized 1
Symptomatic PSP or Large PSP:
Simple aspiration as first-line treatment 1
- Use 16G or larger cannula (at least 3 cm long)
- Insert in 2nd intercostal space, mid-clavicular line
- Discontinue if resistance felt, excessive coughing, or >2.5 L aspirated
- Obtain post-procedure chest radiograph
If aspiration fails:
2. Secondary Spontaneous Pneumothorax
Small SSP (<1 cm) with Minimal Symptoms:
- Observation with hospitalization
- High flow oxygen (10 L/min) with caution in COPD patients 1
All Other SSP:
Small SSP (<2 cm) in minimally breathless patients <50 years:
- Try simple aspiration first
- Hospital admission for at least 24 hours after successful aspiration 1
Larger SSP or symptomatic patients:
- Chest tube drainage (16-22F for stable patients)
- Larger tubes (24-28F) for unstable patients or those requiring mechanical ventilation 1
- Connect to underwater seal with or without suction
3. Unstable Patients (Any Pneumothorax)
- Immediate chest tube placement
- Hospitalization
- Stabilization before any further procedures 1
Chest Tube Management
- Post-insertion: Obtain chest radiograph to confirm position
- Drainage system: Connect to underwater seal device
- Important: Never clamp a bubbling chest tube (risk of tension pneumothorax) 2
- Persistent air leak: If continuing beyond 48 hours, consult respiratory specialist
- Suction: Consider applying -10 to -20 cm H₂O if lung fails to re-expand 2
Chest Tube Removal Criteria
- No air leak
- Lung fully expanded on chest radiograph
- Drainage <100-150 mL per 24 hours (for effusions/hemothorax) 2
Recurrence Prevention
After First Recurrence:
- Surgical management is preferred (very good consensus) 1
- Medical or surgical thoracoscopy
- Staple bullectomy with pleural symphysis procedure
- Options for pleural symphysis: parietal pleurectomy, talc poudrage, or parietal pleural abrasion
Chemical Pleurodesis (for non-surgical candidates):
Follow-up Care
- Avoid air travel until complete resolution confirmed by chest radiograph
- Permanently avoid diving after pneumothorax unless bilateral surgical pleurectomy performed
- Follow-up within 7-10 days after discharge
- Strong emphasis on smoking cessation to reduce recurrence risk 2
Important Clinical Considerations
- Breathless patients should not be left without intervention regardless of pneumothorax size 1
- Persistent air leaks have different resolution patterns:
- In PSP: 75% resolve by 7 days, 100% by 15 days
- In SSP: 61% resolve by 7 days, 79% by 14 days 3
- Consider surgical intervention for air leaks persisting beyond 14 days 3
- Supplemental oxygen accelerates pneumothorax reabsorption four-fold 1